Provider Demographics
NPI:1588000517
Name:ROBERTSON, WENDY NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:NICOLE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18809 E STONEBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-7713
Mailing Address - Country:US
Mailing Address - Phone:918-906-0783
Mailing Address - Fax:
Practice Address - Street 1:2221 W DETROIT ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3628
Practice Address - Country:US
Practice Address - Phone:918-615-6492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1843225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist